TY - JOUR
T1 - Portuguese-Brazilian evidence-based guideline on the management of hyperglycemia in type 2 diabetes mellitus
AU - Bertoluci, Marcello Casaccia
AU - Salles, João Eduardo Nunes
AU - Silva-Nunes, José
AU - Pedrosa, Hermelinda Cordeiro
AU - Moreira, Rodrigo Oliveira
AU - Da Silva Duarte, Rui Manuel Calado
AU - Da Costa Carvalho, Davide Mauricio
AU - Trujilho, Fábio Rogério
AU - Dos Santos Raposo, João Filipe Cancela
AU - Parente, Erika Bezerra
AU - Valente, Fernando
AU - De Moura, Fábio Ferreira
AU - Hohl, Alexandre
AU - Melo, Miguel
AU - Araujo, Francisco Garcia Pestana
AU - De Araújo Principe, Rosa Maria Monteiro Castro
AU - Kupfer, Rosane
AU - Costa E Forti, Adriana
AU - Valerio, Cynthia Melissa
AU - Ferreira, Hélder José
AU - Duarte, João Manuel Sequeira
AU - Saraiva, José Francisco Kerr
AU - Rodacki, Melanie
AU - Castelo, Maria Helane Costa Gurgel
AU - Monteiro, Mariana Pereira
AU - Branco, Patrícia Quadros
AU - De Matos, Pedro Manuel Patricio
AU - De Melo Pereira De Magalhães, Pedro Carneiro
AU - Betti, Roberto Tadeu Barcellos
AU - Réa, Rosângela Roginski
AU - Trujilho, Thaisa Dourado Guedes
AU - Pinto, Lana Catani Ferreira
AU - Leitão, Cristiane Bauermann
PY - 2020/5/24
Y1 - 2020/5/24
N2 - Background: In current management of type 2 diabetes (T2DM), cardiovascular and renal prevention have become important targets to be achieved. In this context, a joint panel of four endocrinology societies from Brazil and Portugal was established to develop an evidence-based guideline for treatment of hyperglycemia in T2DM. Methods: MEDLINE (via PubMed) was searched for randomized clinical trials, meta-analyses, and observational studies related to diabetes treatment. When there was insufficient high-quality evidence, expert opinion was sought. Updated positions on treatment of T2DM patients with heart failure (HF), atherosclerotic CV disease (ASCVD), chronic kidney disease (CKD), and patients with no vascular complications were developed. The degree of recommendation and the level of evidence were determined using predefined criteria. Results and conclusions: In non-pregnant adults, the recommended HbA1c target is below 7%. Higher levels are recommended in frail older adults and patients at higher risk of hypoglycemia. Lifestyle modification is recommended at all phases of treatment. Metformin is the first choice when HbA1c is 6.5-7.5%. When HbA1c is 7.5-9.0%, dual therapy with metformin plus an SGLT2i and/or GLP-1RA (first-line antidiabetic agents, AD1) is recommended due to cardiovascular and renal benefits. If an AD1 is unaffordable, other antidiabetic drugs (AD) may be used. Triple or quadruple therapy should be considered when HbA1c remains above target. In patients with clinical or subclinical atherosclerosis, the combination of one AD1 plus metformin is the recommended first-line therapy to reduce cardiovascular events and improve blood glucose control. In stable heart failure with low ejection fraction (< 40%) and glomerular filtration rate (eGFR) > 30 mL/min/1.73 m2, metformin plus an SGLT-2i is recommended to reduce cardiovascular mortality and heart failure hospitalizations and improve blood glucose control. In patients with diabetes-associated chronic kidney disease (CKD) (eGFR 30-60 mL/min/1.73 m2 or eGFR 30-90 mL/min/1.73 m2 with albuminuria > 30 mg/g), the combination of metformin and an SGLT2i is recommended to attenuate loss of renal function, reduce albuminuria and improve blood glucose control. In patients with severe renal failure, insulin-based therapy is recommended to improve blood glucose control. Alternatively, GLP-1RA, DPP4i, gliclazide MR and pioglitazone may be considered to reduce albuminuria. In conclusion, the current evidence supports individualizing anti-hyperglycemic treatment for T2DM.
AB - Background: In current management of type 2 diabetes (T2DM), cardiovascular and renal prevention have become important targets to be achieved. In this context, a joint panel of four endocrinology societies from Brazil and Portugal was established to develop an evidence-based guideline for treatment of hyperglycemia in T2DM. Methods: MEDLINE (via PubMed) was searched for randomized clinical trials, meta-analyses, and observational studies related to diabetes treatment. When there was insufficient high-quality evidence, expert opinion was sought. Updated positions on treatment of T2DM patients with heart failure (HF), atherosclerotic CV disease (ASCVD), chronic kidney disease (CKD), and patients with no vascular complications were developed. The degree of recommendation and the level of evidence were determined using predefined criteria. Results and conclusions: In non-pregnant adults, the recommended HbA1c target is below 7%. Higher levels are recommended in frail older adults and patients at higher risk of hypoglycemia. Lifestyle modification is recommended at all phases of treatment. Metformin is the first choice when HbA1c is 6.5-7.5%. When HbA1c is 7.5-9.0%, dual therapy with metformin plus an SGLT2i and/or GLP-1RA (first-line antidiabetic agents, AD1) is recommended due to cardiovascular and renal benefits. If an AD1 is unaffordable, other antidiabetic drugs (AD) may be used. Triple or quadruple therapy should be considered when HbA1c remains above target. In patients with clinical or subclinical atherosclerosis, the combination of one AD1 plus metformin is the recommended first-line therapy to reduce cardiovascular events and improve blood glucose control. In stable heart failure with low ejection fraction (< 40%) and glomerular filtration rate (eGFR) > 30 mL/min/1.73 m2, metformin plus an SGLT-2i is recommended to reduce cardiovascular mortality and heart failure hospitalizations and improve blood glucose control. In patients with diabetes-associated chronic kidney disease (CKD) (eGFR 30-60 mL/min/1.73 m2 or eGFR 30-90 mL/min/1.73 m2 with albuminuria > 30 mg/g), the combination of metformin and an SGLT2i is recommended to attenuate loss of renal function, reduce albuminuria and improve blood glucose control. In patients with severe renal failure, insulin-based therapy is recommended to improve blood glucose control. Alternatively, GLP-1RA, DPP4i, gliclazide MR and pioglitazone may be considered to reduce albuminuria. In conclusion, the current evidence supports individualizing anti-hyperglycemic treatment for T2DM.
KW - ASCVD
KW - Atherosclerotic disease
KW - Cardiovascular risk
KW - Chronic kidney disease
KW - Diabetes treatment
KW - Guidelines
KW - Heart failure
KW - Ischemic heart disease
KW - Type 2 diabetes
UR - http://www.scopus.com/inward/record.url?scp=85085482173&partnerID=8YFLogxK
U2 - 10.1186/s13098-020-00551-1
DO - 10.1186/s13098-020-00551-1
M3 - Review article
C2 - 32489427
AN - SCOPUS:85085482173
VL - 12
JO - Diabetology and Metabolic Syndrome
JF - Diabetology and Metabolic Syndrome
IS - 1
M1 - 45
ER -